Chylous ascites
Primary maldevelopment of the intra-abdominal lymphatic vessels predisposes to disruption of lymphatic flow resulting in non-traumatic leakage of chyle through intestinal villi into the abdominal cavity resulting in chylous ascites. Chylous ascites typically presents with abdominal distention and discomfort, clinical dehydration, malnutrition, electrolyte imbalance, peripheral edema and immunosuppression. Hypoproteinemia, specifically hypoalbuminemia, can cause decreased vascular oncotic pressure and cause “third-spacing” soft tissue edema.
Congenital causes like intestinal lymphangiectasia or lymphatic malformations demonstrate disrupted or dilated lymphatic vessels that are prone to exudative leakage of lymphatic fluid through a fistula into the peritoneum (Figure 1b) .[1] Steinmann et al reviewed 190 patients with chylous ascites noting 32% were caused by lymphatic anomalies. Furthermore, 84% of these predominantly pediatric vascular anomalies were classified as lymphangiectasia or Waldmann’s disease (dilated lymphatic vessels that lack valves in the submucosa of the small bowel).[8]
Paracentesis plays both a diagnostic and therapeutic role in the management of chylous ascites. In the feeding child, chyle aspirated via abdominal paracentesis appears milky white in appearance and biochemical analysis demonstrates elevated triglyceride concentration >110 mg/dl (similar to chylous effusions mentioned above).